Vitality Members

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1. Basic information
Age
Gender
ID number
Cell number
Contact numbers
Email address
Contact person in case of an emergency
Cell
Home
Work
Relation
2. Do you.... If yes please X the box
3. If yes, please X the box
4. Are you currently, if yes please X the box
If yes, how far along: Complications:
Date of last medical exam:
Do you ever suffer from back ache YES / NO, if yes specifically:
List of serious surgeries:
Date:
List of serious illness:
Date:
Do you suffer from major pain or discomfort during exercises?
Do you suffer from major pain or discomfort during exercises?
Specifically:
Are you majorly affected by stress and / or suffer from anxiety and/or excessive tension?
Are you majorly affected by stress and / or suffer from anxiety and/or excessive tension?
How many hours sleep do you get on average per night
Are you taking any prescription medication?
Are you taking any prescription medication?
Do you suffer from unexplained stiffness or cramps?
Do you suffer from unexplained stiffness or cramps?
If yes, namely
If yes how many hours a week, please specify:
Do you play sports or do any take part in other recreational activities
Do you play sports or do any take part in other recreational activities
How many alcoholic beverages do you consume per week on average:
What are your reasons for exercising
If you are an ex-smoker, for how long have you stopped?
What would you like to achieve out of the fitness program
Do you battle to keep your weight consistent
Do you battle to keep your weight consistent
Do you eat a balanced diet
Do you eat a balanced diet
Do you take supplements of any kind?
Do you take supplements of any kind?
If yes please specify,
I, Full Name
state that to the best of my knowledge the above is true.
state that to the best of my knowledge the above is true.
MM slash DD slash YYYY
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